Corneal Epithelial Defect

From EyeWiki
Original article contributed by: Joanna Hudson Queen, MD
All contributors: Erica Bernfeld M.D. and Joanna Hudson Queen, MD
Assigned editor: Erica Bernfeld
Review: Assigned status Update Pending by Joanna Hudson Queen, MD on December 1, 2014.


Summary

Corneal epithelial defects are focal area of epithelial (outermost corneal layer) loss; can be due to mechanical trauma, corneal dryness, neurotrophic cornea, post surgical changes or any other of a variety of etiologies. Corneal epithelial defects are one of the most commonly seen ocular pathologies in the general patient population.

Etiology

Corneal epithelial defects are a focal loss of the corneal epithelium and can occur by a variety of means.

  • Mechanical trauma ( e.g. fingernail scratch, contact lens overuse, foreign body in the lid/fornices, trichiasis/distichiasis, chemical exposure)
  • Exposure ( e.g. neurotrophic diseases causing incomplete lid closure (commonly cranial nerve seven palsy), restrictive eyelid diseases, proptosis, decreased consciousness in drug abuse or comatose state, blepharoplasty, lagophthalmos)
  • Ultraviolet burns (e.g. welding, prolonged sun exposure off reflective surfaces)
  • Local corneal dryness and systemic disorders leading to corneal dryness (e.g. dry eye syndrome, thyroid eye disease, Sjogren’s syndrome, vitamin A deficiency)
  • Limbal stem cell deficiency ( failure to regenerate epithelial cells, occurs from a variety of causes e.g. chemical burns, post ocular surgery, ocular autoimmune degenerations)
  • Topical anaesthetic abuse
  • Neurotrophic keratopathy (corneal hypoesthesia or anaesthesia caused, most frequently, by damage to the trigeminal nerve, also HSV, VZV, topical drop toxicity, among others)

Risk Factors

Refer to Etiology

Primary prevention

Modification of risk factors for corneal abrasions including protective eye wear for UV exposure and foreign bodies, treatment of pre-existing corneal dryness/dry eye syndrome, abstaining from eye rubbing, etc.

Diagnosis

When visualizing corneal defects, fluorescein dye is instilled either as a liquid drop (mixed with a topical anaesthetic) or via a fluorescein impregnated paper strip after the instillation of topical anaesthetic. The dye is visualized using a cobalt-blue filter which causes the dye to fluoresce a bright green color. Fluorescein does not stain intact corneal epithelium but does stain corneal stroma, thus demarcating the area of the epithelial loss. The distribution, size and shape of the corneal defect will vary depending on the etiology (e.g. thin, linear defect for fingernail scratch, whole corneal surface defect for an extensive chemical burn, inferior corneal irregular defect for lid abnormalities/lagophthalmos).

Signs

A focal area of corneal fluorescein uptake is an obligatory sign. Conjunctival injection is frequently present on the ipsilateral side of the corneal defect. Periorbital skin or lid changes are present variably given the etiology of the defect (e.g. skin burns with chemical exposures, periorbital trauma in post-motor vehicle collision defects, poor lid closure in exposure defects).

Symptoms

Symptoms include pain, tearing and foreign body sensation of the affected eye (the exception being neurotrophic keratopathy) which are commonly alleviated by the instillation of topical anaesthetic. They can also be accompanied by photophobia, pain with blinking and pain with eye movement.

Occurrence

Corneal epithelial defects accounted for 10% of all eye-related emergency room visits in the early 1990s. They are a common, and frequently overlooked, ocular pathology. Specific occurrences vary by etiology of epithelial defect.

Physical Exam

A thorough history is required to determine the etiology of the corneal defect. Similarly, a thorough exam of both eyes is needed because in many cases of systemic diseases or trauma both eyes can be affected.

Management

Several techniques exist for the management of corneal epithelial defects. Which technique is utilized depends on the defect's extent, patient compliance and provider preference. For small defects, observation is an acceptable treatment, with or without topical antibiotics to prevent infection given the mechanism of injury or provider suspicion. For large defects, bandage contact lenses and pressure patching can be administered in patients with history of good follow up. The goal of treatment is to provide patient comfort and prevent infection as the limbal stem cell regenerate the corneal epithelium.

Topical anesthetics are not considered to be helpful in the treatment of corneal epithelial defects due to the concern for topical anesthetic abuse and masking of worsening pain/symptoms/infection by continuous anesthesia.

Medical follow up

Patients should be followed closely in the clinic to ensure resolution of the defect and to monitor for signs of infection.

Additional Resources

  1. External Disease and Cornea. Basic and Clinical Science Course, Section 8. San Francisco: American Academy of Ophthalmology. 2017-2018
  2. American Academy of Ophthalmology. Persistent corneal epithelial defect. Practicing Ophthalmologists Learning System, 2017–2019 San Francisco: American Academy of Ophthalmology, 2017.
  3. Practical Ophthalmology, 6th Edition. San Francisco: American Academy of Ophthalmology. 2009
  4. Shields T, Sloane PD. A comparison of eye problems in primary care and ophthalmology practices. Fam Med. Sep-Oct 1991;23(7):544-6. [Medline].